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MARK MORAN / THE CITIZENS’ VOICE Luzerne County Coroner Bill Lisman said toxicology reports for all 11 heroin/morphine-related overdose deaths last year came back showing sometimes seven or eight other drugs.

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No single cause explains drug use. No single way exists to prevent it. And, often, no single drug leads to a lethal overdose.

The Luzerne County Coroner’s Office reported 13 heroin-related overdose deaths this year, but heroin alone accounted for only two of them. The remaining deaths resulted from polypharmacy overdoses, a blanket term used to describe overdoses that result from the use of a combination of drugs. In the case of heroin-related overdoses, it means a mix of morphine with other, often legal, drugs.

Although heroin use has soared nationwide in the last decade, heroin-related overdoses throughout the county stem from what users and sometimes pushers mix with the heroin to create these polypharmacy cocktails.

Luzerne County Coroner Bill Lisman said toxicology reports for all 11 heroin/morphine-related overdose deaths came back showing sometimes seven or eight other drugs, not including morphine.

“Everyone seems to think it’s all about heroin,” Lisman said.

Lisman explained that toxicology reports for overdose deaths often come back showing “therapeutic” levels of the non-morphine-based drugs. At a therapeutic level, he said, these drugs alone won’t kill individuals. A drug can be lethal at a therapeutic level when combined with morphine and small amounts of other drugs.

Heroin, which is synthesized from morphine, can be injected, snorted or smoked. According to the National Institute of Drug Abuse, all three routes rapidly deliver the drug to the brain where the morphine binds to molecules on cells, known as opioid receptors, located on the brainstem. The brainstem controls automatic processes critical for life, such as blood pressure, arousal and respiration. Heroin overdoses frequently involve a suppression of breathing, which can be fatal on its own. When heroin is added into a mix of prescription painkillers — opioid or narcotic pain relievers — the effects are intensified and the likeliness of an overdose increases.

Following an initial surge of euphoria, users enter an alternately wakeful and drowsy state, and can slip into a coma.

The majority of the patients with heroin addictions at Wyoming Valley Alcohol and Drug Services Inc. — as well as drug users in general — were introduced to opiates when they started using prescription painkillers, said Jason Harlen, CEO of the treatment center with offices in Wilkes-Barre and Pittston. The center sees about 4,000 patients a year.

Once the crossover to heroin is made, “They’re always chasing that feeling of the first time.”

A significant amount of heroin users who come through the facility also maintain a polypharmacy habit. A number of factors contribute to this, Harlen said.

Part of the reason is because painkillers are accessible from pharmacies, nearby medicine cabinets and on the street. Another part of it is pills, although more expensive, intensify the high of an average heroin user when added into the mix.

“It’s like taking a shot with a beer,” Harlen said. “People try to get a more extravagant high.”

This also helps spread out the supply of heroin by cutting back while also postponing opiate withdrawal, which can start setting in within hours after the last fix, Harlen said.

Lisman said drug users in Northeastern Pennsylvania don’t seem to realize how lethal these polypharmacy cocktails can be. He cited the widely reported rash of overdoses on fentanyl-mixed heroin, known as “theraflu,” that hit Allegheny County in Western Pennsylvania. According to the Centers for Disease Control and Prevention, fentanyl is estimated to be 80 times more potent than morphine and hundreds of times more potent than heroin. When combined with other opiates, it can be fatal.

Lisman said the theraflu outbreak never touched down in Luzerne County like it did in cities like Pittsburgh, but he had cases where he found drug users with fentanyl patches in their mouths in addition to having other drugs, often morphine, in their systems.

Fentanyl patches, often prescribed to patients in severe pain, such as cancer patients, are designed to be worn on the skin, administering a steady dose of medication for about three days. Lisman said drug users will sometimes “chew the patches like bubblegum” to release all three days worth of the medication in one shot.

One of the things making pharmaceuticals in these drug cocktails accessible is the lax regulations on the pharmaceutical industry, said Carmen Ambrosino, former CEO of Wyoming Valley Alcohol and Drug Services Inc. and current co-chairman of the governor-appointed, eight-members board for the Pennsylvania Advisory Council on Drug and Alcohol Abuse. For example, he said 45 states have Pharmaceutical Accountability Monitoring Systems that cut down on patients obtaining controlled substances from multiple health care practitioners without the prescribers’ knowledge of the other prescriptions. The monitoring systems alert a health care practitioner if a patient has already been elsewhere to fill a prescription. Pennsylvania does not have this system.

One method used to combat drug overdose deaths that’s gained a lot of support is Narcan (Naloxone), classified as an opiate antagonist.

State Rep. Gene DiGirolamo, chairman of the House Human Services Committee, in June led the committee in unanimously drafting legislation, sponsored by himself and state Rep. Dan Frankel, to prevent overdose deaths by ensuring police, firefighters, first responders and others have access to Narcan, which can stop an overdose in progress.

“Narcan is absolutely a miracle drug. Emergency personnel have been using it for years,” DiGirolamo said. “As long as you have one breath left, it instantaneously bleaches the opiates out of the body.”

Timothy Balla, operations supervisor for Trans-Med Inc., based in Luzerne, has frequently used Narcan in his 10 years working as a paramedic. The drug can be used on an unresponsive patient with low to no pulse and shallow breathing. The preferred practice is to inject Narcan, Balla said. If emergency personnel can’t find a vein to inject the drug, they will use the nasal spray version. Either way is safe, quick and effective, he said.

“If you can get IV access, it acts quicker (than the nasal spray),” Balla said. “No one reacts quite the same, but it takes effect in 30 seconds to 1½ minutes.”

He said people wake up alert and aware of what’s going on, but because Narcan takes opiates out of the bloodstream almost immediately, the person goes right into withdrawal. Overdoses comes in waves in this area, he said. There’s times he won’t use Narcan for a couple weeks and others he uses it eight times in a seven-day period.

“We’re seeing a spike in opiate overdoses in the past several months,” Balla said. “Seems to be rearing their ugly heads again.”

Last year, Senate Bill 1164, known as the Good Samaritan drug overdose law, passed with a 50-0 vote. The bill amends the state’s controlled substance law to offer drug users immunity from prosecution for certain drug crimes when they call for help when a person they are with experiences a drug overdose. Immunity is granted only if a person calls 911, gives authorities identifying information about himself or herself and stays with the overdose patient until first responders arrive.

The House passed the bill by a vote of 177-26 in December with an amendment that would not only put Narcan in the hands police and firefighters but also in the hands of family members or friends of someone at risk for an overdose, as well as their loved ones. The bill awaits another senate vote before it’s final passage, DiGirolamo said.

If the bill passes, Narcan would be available with a doctor’s prescription. DiGirolamo said it’s even safe to use on someone who didn’t overdose.

jseibel@citizensvoice.com

570-821-2110, @cvseibel

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